MEDICARE: THERESA MARIE BERGIN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	PA9104797	FL
2	363AM0700X	Medical Physician Assistant	PA9104797	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114170222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	THERESA MARIE BERGIN PA-C

Provider Business Mailing Address
First Line	:	1507 S HIAWASSEE RD
Second Line	:	STE 107
City	:	ORLANDO
State	:	FL
Zip	:	32835-5706
Country	:	US
Telephone Number	:	407-445-9545
Fax Number	:	407-299-9141

Provider Business Practice Location Address
First Line	:	1507 S HIAWASSEE RD
Second Line	:	STE 107
City	:	ORLANDO
State	:	FL
Zip	:	32835-5706
Country	:	US
Telephone Number	:	407-445-9545
Fax Number	:	407-299-9141

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/03/2008
Last Update Date	:	10/01/2020

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Directions to “ THERESA MARIE BERGIN PA-C” Practice Location

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